Labor Continued
Cesarean Birth
Cesarean birth is the delivery of a fetus by way of an incision through the woman’s abdominal wall and uterus. The goal of a Cesarean delivery is to preserve the life and/or health of the mother, the fetus, or both.
Elective Cesarean
An elective Cesarean is a planned Cesarean birth most commonly due to previously known conditions such as:
- Previous Cesarean delivery
- Breech or Other Malpresentation
- CPD (Cephalo-Pelvic Disproportion)
- PIH (Pregnancy-Induced Hypertension) Toxemia
- Placenta Previa
- Abruptio Placenta
- Herpes Type 2 Infection
- Pelvic Tumors
- Maternal Gonorrhea
- Maternal Insulin-Dependent Diabetes
- Maternal complications which might be exacerbated by labor and delivery
Unplanned Cesarean
An unplanned Cesarean birth most commonly occurs due to the following factors:
- Fetal Distress
- Failure to Progress
- Failure to dilate in labor
- Failure of the fetus to descend after 2+ hours of 2nd stage pushing (bearing down efforts) without regional anesthesia.
- CPD (Cephalo-Pelvic Disproportion)
- Breech or Other Malpresentation
- Placenta Previa
- Abruptio Placenta
- Cord Prolapse
- PIH (Pregnancy-Induced Hypertension) Toxemia
- Maternal Fever
Pre-Operative Preparation
Consents
The woman must sign a consent for the Cesarean delivery and anesthesia. Some hospitals may also require a consent to be signed allowing the woman’s coach to be present in the Cesarean delivery room.
History and Physical
A history form is completed by the RN and a physical form is completed by the MD.
Laboratory Tests
Blood is drawn and sent to the laboratory for a routine CBC hematocrit and hemoglobin levels, bleeding times, etc. Urine is also sent to the lab for a routine urinalysis, protein and sugar levels, etc.
Ultrasound
An ultrasound may be ordered to ascertain the fetal presenting part, quantity of amniotic fluid, location of placenta, approximate fetal age, etc.
Enema
An enema is administered to evacuate and cleanse the lower bowel.
Prep
The prep is an abdominal shave which removes body hair from approximately the level of the woman’s navel to the pubic hair above and around the pubis.
IV (Intravenous)
An intravenous line is established for the infusion of fluids and medications.
Catheter
Insertion of a urinary catheter into the bladder allows the constant draining of urine from the bladder and the reduction of its size or volume.
Cesarean Birth-Operative Procedures and Recovery
Anesthesia
Regional Anesthesia
Anesthesia which numbs a region of the body usually without loss of consciousness.
Spinal Anesthesia-A regional anesthetic which numbs the body from the chest to the toes. Spinal anesthesia blocks sensory (pain) nerves and motor (movement) nerves.
Epidural Anesthesia-A regional anesthesia which numbs the body from the chest to the toes. Epidural anesthesia blocks sensory (pain) nerves and decreases transmission by the motor (movement) nerves.
General Anesthesia
Complete absence of sensation with loss of consciousness.
Sterile Drape
A sterile drape is place completely over the woman’s body and positioned as a visual and physical barrier to the surgery at the level of the woman’s chest.
Incisions
The incision on the abdominal wall may not reflect, or match, the incision on the uterus. For the sake of this discussion, however, we will assume that the two incisions correspond to one another.
Bikini Cut (Pfannenstiel) and Low Transverse Incision
The skin incision is a horizontal incision through the low abdominal wall at the first skin crease under the pubic hair line. The uterine incision is a horizontal incision through the lower uterine segment.
Midline Skin and Classical Incision
The skin incision is a vertical incision through the abdominal wall between the umbilicus and the pubis. The uterine incision is a vertical incision through either the mid-segment of the uterus or the lower segment of the uterus.
Length of Surgery
From the time that the surgical delivery commences, the fetus is usually delivered in less than 5 minutes. After that it can take from 30-55 minutes to suture the various tissue layers, apply sterile dressings to the abdominal wound, clean the patient, and transfer her to the recovery room for observation. During the immediate post-delivery time, but prior to the woman being transferred to the recovery room, the new mother will usually have an opportunity to see and touch her baby. The infant is usually accompanied to the nursery by the pediatrician and the woman’s coach.
Recovery Room
Most Cesarean patients stay in the recovery room for 1-2 hours. During this time the patient is assessed for stability of vital signs, fundal firmness, lochia flow, and level of anesthesia. Once the patient is determined to be stable, TED hose (support stockings) are put on her legs to facilitate blood return to the heart and to reduce the possibility of blood clots, and her peri pads are changed. The woman is then transferred to her postpartum room.
Hospital Stay
After a Cesarean delivery, the new mother can expect to stay in the hospital anywhere from 2-4 days, barring complications. Breastfeeding can usually be initiated immediately upon presentation of the infant to the new mother in her postpartum room. The urinary catheter is usually removed the day after the delivery. The intravenous (IV) is usually removed once the woman is taking oral fluids adequately and resumes a normal diet. The new mother will be encouraged by the nurses to get out of bed and become mobile in small increments as soon as possible to reduce post-surgical complications and abdominal gas pains.
Cesarean Birth Options
Following is a short list of options which the woman and her coach may request of her obstetrician, anesthesiologist, pediatrician and/or nurses in the event of a Cesarean birth. As there are options, it is understood that these requests may or may not be granted upon the condition of the mother, the baby, or both.
- Coach present for delivery
- Type of anesthesia: Regional or general.
- Type of incision: Bikini/low segment or classical.
- Mother may wear glasses during delivery.
- Doctor speaking to the patient in general terms during delivery, not having discussions with colleagues while ignoring presence of the new mother.
- Possibility of the physician dropping the drape so that the mother may see the baby delivered as the anesthesiologist props the woman’s head up.
- Mother may see and touch the new baby prior to its leaving the delivery room for the nursery.
- A private room for the postpartum hospital stay. If a shared room is provided, request a Cesarean roommate.
Cesarean Considerations
A Cesarean delivery is major abdominal surgery with increased risks of infection, bleeding, anesthesia complications, and maternal mortality two to four times greater than that for a vaginal delivery.
The Cesarean delivery rate in the United States is approximately 25%.
More than one-third of these Cesarean deliveries are for repeat Cesareans. ACOG (The American College of Obstetricians and Gynecologists) recommends a trial of labor and VBAC (vaginal birth after Cesarean) for most of these women when an identified indication for repeat surgery does not exist.
The possibility of rupture of the uterine scar is less than 0.25% now that most incisions on the uterus are low and horizontal. Consequently, a woman who has had a previous Cesarean delivery is not required to have a repeat Cesarean delivery unless a documented medical condition exists and warrants it.
Seven out of ten women who have had a Cesarean delivery for “failure to progress” in one labor have had successful trials of labor and vaginal deliveries with a subsequent pregnancy.
Overdiagnosis of fetal distress, routine repeat Cesarean deliveries, and overdiagnosis of “failure to progress” are the three most common medical causes contributing to the increase in Cesarean deliveries.
A Cesarean delivery can cost as must as twice that of a vaginal delivery.
Documentation shows that women with private insurance, who have higher educational levels, are older, are married, and are in a higher socio-economic bracket are more likely to have a Cesarean delivery.
Hospitals which have initiated programs delineating rules as to when a Cesarean may be performed, and follow-up evaluation of each Cesarean, have decreased their Cesarean delivery rate.
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